New guidelines reopen the great swaddling debate

A new set of guidelines from the Registered Nurses' Association of Ontario is highlighting the risks associated with swaddling infants, yet again reopening the debate on the popular practice.

Swaddling -- the practice of tightly wrapping an infant in a blanket to promote sleep – is popular among some parents, but research on swaddling is divided.

The practice was one of several examined in the RNAO guidelines, which were developed to help create a list of recommendations on how to create safe sleeping environments for infants.

The guidelines are meant to help health care providers and patients make decisions about their care. To develop them, the association looked at the current evidence on a number of issues related to infant health and sleep.

According to the guidelines, some studies have reported that swaddling may increase the risk of Sudden Infant Death Syndrome. Research indicates that the risk for SIDS may be more significant when swaddled infants are placed on their stomachs, the guidelines state.

According to the guidelines, swaddling also carries a risk of overheating. It can also lead to the blanket coming loose in the infants' sleep environment, which poses additional dangers including suffocation.

"There is currently no evidence on the 'safe way' to swaddle an infant, and hence caution regarding swaddling should be expressed with parents/caregivers," the guidelines say.

Pediatric nurse Patricia Maddalena helped develop the RNAO guidelines. She said swaddling can also decrease "arousal" – how easily an infant baby awakens from sleep -- which may be associated with an increased risk for SIDS.

"That's one of the purposes of swaddling to soothe a fussy baby and to promote longer sleep," she told CTV's Canada AM. "We don't really know what causes SIDS, but there does seem to be some alterations in arousal mechanisms in the brain, and decreasing arousal in babies may be associated with an increased risk for SIDS. So it may not be the best thing to do, to wrap babies tightly."

Last October, a study warned that swaddling an infant may be linked to the development of hip abnormalities later in life. Depending on how the baby is swaddled, the practice may force the hips to straighten and shift forward, which may increase the risk of osteoarthritis and the need for a hip replacement in middle age, the study found.

Maddalena said that while the RNAO guidelines do not produce firm recommendations on swaddling, hospitals are increasingly abandoning the practice.

"There is no definitive recommendation against swaddling, but more and more hospitals are not endorsing the practice and are moving away from it," she said.

"In the clinic that I work in… we don't encourage swaddling. We would work with families to identify other ways to help infants get to sleep and soothe babies."

The association concluded that the safest way for infants to sleep is on their backs, alone, and in a crib that meets Canadian safety standards.

Parents are urged to avoid using blankets, pillows and other types of sleep aids such as head coverings and soft toys in the sleep environment.

Nurse practitioner Elyse Maindonald said that while many parents believe blankets and head coverings are necessary to keep their baby warm, research suggests otherwise.

"Infants over two months of age who are overheated are actually at an increased risk of SIDS,” she said in a statement.

Maddalena said parents concerned about keeping their infant warm in the winter should consider layering sleepers on their infant or using a properly fitting "sleep sack" – a wearable blanket -- instead.